Nursing News

Decreased Interruptions Lead to More Time at the Bedside

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By Megan M. Krischke, contributor

A nurse at Virginia Mason Medical Center retrieves medications from the prescription refrigerator.

March 18, 2011 - A nurse’s workday is often characterized by interruptions, partly because many patient needs simply can’t be put on a schedule. There are additional interruptions from co-workers, patients’ family members, pages and so on. While some interruptions are unavoidable, each one leads to time wasted as the nurse returns to his or her previous task and has to spend time refocusing and evaluating what parts of the task were complete and what remains to be done.

In addition to time lost, it is commonly believed that these interruptions also increase errors.

Virginia Mason Medical Center (VMMC) in Seattle, Wash., has made several changes in their nursing care in recent years that have decreased nurse interruptions and have led to significant increases in the time nurses are able to spend at the bedside.

“One of the key areas in which we are seeking to decrease interruptions is during medication administration,” commented Joan Ching, RN, MN, CPHQ, director of hospital quality and safety at VMMC. “A recent study [Westbrook, Archives of Internal Medicine, April 2010] showed that each time a nurse was interrupted during medication administration, the risk of an error occurring increased by 12 percent.”

VMMC began trying to decrease interruptions by using visual cues. While administering medicines, nurses placed a flashing red light or a large red sign on top of their computer on wheels, to indicate that they should not be interrupted.

“Unfortunately, if someone wasn’t from that unit, say a patient’s family member, a physician or someone from nutritional services, they didn’t understand the cue and would interrupt the nurse,” explained Ching. “So we decided to focus on what we could control, which was when the nurse was at the automated dispensing cabinet.”

Since VMMC did not have the space or resources to completely isolate the cabinet, they marked off the area with red tape and placed a sign above the area indicating that there should be no talking when a nurse was working at the cabinet. Over the course of 2010, VMMC saw a decrease in the percentage of interrupted medication administrations from 48 percent to 29 percent.

“Every time a nurse is interrupted for something non-urgent, it takes him or her off task. Even if you are physically near your patients, interruptions make you more mentally unavailable,” said Ching. “Being able to focus adds value to the whole care process because you are more present with the patient. “

“We are also working with nurses on scripts to use when they are being interrupted, but need to maintain focus,” she continued. “We don’t want patients and family members to feel like they can’t approach the nurses, so we acknowledge their presence and explain that we can’t be interrupted, but that we will get back with them shortly.”

“Hospitals involved with the Transforming Care at the Bedside project are experimenting with different ways to decrease interruptions. One unit implemented a welcome letter that they gave to family members that encouraged families to call at a certain time in the morning, after rounds. The nurses then spent time dedicated to answering calls instead of being paged throughout the day,” remarked Janet Moye Ph.D., RN, NEA-BC, associate director of quality improvement for the Aligning Forces for Quality program sponsored by the Robert Wood Johnson Foundation.

“Another unit instituted a quiet time,” she added. “During this time, nurses encourage patients to rest and discourage other activity in the unit such as patient transfers, testing, and visits from other units. Nurses then use this time to chart, prepare medications, or complete their shift reports.”

“Nurses should be given a quiet place to chart,” mentioned Debora Simmons, RN, MSN, CPRN, CCNS, from the University of Texas, National Center for Cognitive Informatics and Decision Making in Healthcare. “Also, management should do a workflow analysis in order to create an electronic medical record that is user-friendly. Tools should assist, not impede or interrupt, a nurse’s work.”

Providers at VMMC have found that doing rounds as an interdisciplinary team of physician, nurse and pharmacist reduces the number of pages nurses need to send to physicians throughout the rest of the shift—decreasing interruptions for both.

“Our nursing teams did a tremendous amount of work in 2005 and 2006 around improving time at the bedside,” commented Ching. “What they developed are geographic cells where nurses see patients in rooms that are clustered together and they placed frequently used supplies into patient rooms; these changes increased nurses’ time at the bedside from 30 percent to 90 percent.”